club foot (CTEV) topic as per the pediatric nursing context

1. NASIR AHMAD (M.Sc. NURSING 2nd YEAR
SPECIALITY: CHILD HEALTH NURSING

2.  CONGENITAL TALIPES
EQUINOVARUS (CTEV)
commonly known as Clubfoot
is one of the most common
congenital musculoskeletal
deformity among newborns.
Although it is called
congenital, it is not an
embryonic malformation but
is developmental deformation
occurring during 2nd trimester.

3.  CTEV or Club foot
describes a range of foot
abnormalities usually
present at birth (congenital)
in which the baby’s foot is
twisted out of shape or
position. In clubfoot the
tissues connecting the
muscles to the bone
(tendons) are shorter than
usual. Clubfoot is a fairly
common birth defect and is
usually an isolated problem
for an otherwise healthy
newborn.

4.  Incidence of CTEV is 1 per 1000, making it the fifth most
common congenital malformation after
cardiovascular anomalies (9 per 1000)
hypospadiasis (3.4 per 1000)
urinary tract malformations (2.4 per 1000) &
Down’s Syndrome (1.5 per 1000).
 Greater incidence is found in male babies as compared to the
female babies.

5.  GENDER-
males are twice as likely as
females to be born with club
foot.
 GENETICS-
if a parent who was born with
club foot, they have a higher
chance of having a child with
the same condition. The risk is
higher if both parents have the
condition.

6.  The clubfoot is mainly idiopathic, the genetic
factors are believed to play a major role and some
specific gene changes have been associated with it,
but this is not yet well understood. It appears to be
passed down through families.
 It is not caused by the fetus’ position in the uterus.
 Sometimes it may be linked to other skeletal
abnormalities, such as spina bifida cystic, or a
developmental hip condition known as hip dysplasia
or developmental dysplasia of the hip (DHH).
 It may be due to a disruption in a neuromuscular
pathway, possibly in the brain, the spinal cord, a
nerve or a muscle.

7.  Environmental factors may play a role. Research has
found a link between the incidence of club foot and
maternal age, as well as whether the mother smokes
cigarettes and if she has diabetes.
 A link has also been noted between chance of
clubfoot and early amniocentesis that is before 13
weeks of gestation during pregnancy.
 Oligohydramnios
 Amniotic Band Syndrome and congenital
constriction rings.
 Increased occurrences in those children with
neuromuscular disorders, such as cerebral palsy and
spina bifida.

8.  The top of the foot is usually twisted downward and
inward, increasing the arch and turning the heel
inward.
 The foot may be turned so severely that it actually
looks as if it’s upside down.
 The affected leg or foot may be slightly shorter.
 The calf muscles in the affected leg are usually
underdeveloped.
 Despite its look, clubfoot itself does not cause any
discomfort or pain. But the difficulty in walking.
 In fact the Achilles tendon is too short.

9.  IDIOPATHIC CLUBFOOT:
Also known as talipes equinovirus, idiopathic club foot is
the most common type of clubfoot and is present at birth.
This congenital anomaly is seen in one out of every 1000
babies, with half of the cases of clubfoot involving only one
foot. There is currently no known cause of idiopathic
clubfoot, but baby boys are twice as likely to have clubfoot
compared to baby girls.
 Neurogenic Clubfoot
Neurogenic clubfoot is caused by an underlying neurologic
condition. For instance, a child born with spina bifida A
clubfoot may also develop later in childhood due to cerebral
palsy or a spinal cord compression.

10.  Syndromic Clubfoot
Syndromic clubfoot is found along with a number of other
clinical conditions, which relate to an underlying syndrome.
Examples of syndromes where a clubfoot can occur include
arthrogryposis, constriction band syndrome (streeter’s
dysplasia), tibial hemimelia & diastrophic dwarfism.

11.  Clubfoot consists of bone deformity and soft tissue
contracture. It has several tissue abnormalities, including
muscle and cartilage anomalies, bone primary germ plasm
defects, and vascular abnormalities such as
hypoplasia/absence of the anterior tibial artery.
 Retracting fibrosis (or myofibrosis) may occur secondary to
increased fibrous tissue in muscles and ligaments, results into
shortening of the Achilles tendon which in turn results the
deformity of the foot.

12.  Most commonly, a doctor recognizes clubfoot soon after birth
just from looking at the shape and positioning of the
newborn's foot. Occasionally, the doctor may request X-rays
to fully understand how severe the clubfoot is, but usually X-
rays are not necessary.
 It's possible to clearly see most cases of clubfoot before birth
during a routine ultrasound exam in 20th of pregnancy. While
nothing can be done before birth to solve the problem,
knowing about the condition may give you time to learn more
about clubfoot and get in touch with appropriate health
experts, such as a paediatric orthopaedic surgeon and a
genetic counsellor.

13.  Because your newborn's bones, joints and tendons are very
flexible, treatment for clubfoot usually begins in the first week
or two after birth. The goal of treatment is to improve the way
your child's foot looks and works before he or she learns to
walk, in hopes of preventing long-term disabilities.
 Treatment options include:
 Stretching and casting (Ponseti method)
 Surgery

14.  This is the most common treatment for clubfoot. The doctor will:
 Move your baby's foot into a correct position and then place it in a
cast to hold it there
 Reposition and recast your baby's foot once a week for several
months
 Perform a minor surgical procedure to lengthen the Achilles tendon
(percutaneous Achilles tenotomy) toward the end of this process
After the shape of your baby's foot is realigned, you'll need to
maintain it with one or more of the following:
 Doing stretching exercises with your baby
 Putting your child in special shoes and braces
 Making sure your child wears the shoes and braces as long as
needed — usually full time for three months, and then at night and
during naps for up to three years
 For this method to be successful, you'll need to apply the braces
according to your doctor's directions so that the foot doesn't return
to its original position. The main reason this procedure sometimes
doesn't work is because the braces are not used as directed.

16.  If your baby's clubfoot is severe or doesn't respond to
nonsurgical treatments, more-invasive surgery may be needed.
An orthopaedic surgeon can lengthen or reposition tendons
and ligaments to help ease the foot into a better position. After
surgery, your child will be in a cast for up to two months, and
then need to wear a brace for a year or so to prevent the
clubfoot from coming back.
 Even with treatment, clubfoot may not be totally correctable.
But in most cases, babies who are treated early grow up to
wear ordinary shoes and lead full, active lives.

17.  Nursing Assessment
 History:- Seek a detailed family history of clubfoot
or neuromuscular disorders, and perform a general
examination to identify any other abnormalities.
 Physical exam. Examine the feet with the child
prone, with the plantar aspect of the feet visualized,
and supine to evaluate internal rotation and varus; if
the child can stand, determine whether the foot is
plantigrade, whether the heel is bearing weight, and
whether it is in varus, valgus, or neutral.

18.  Nursing Diagnosis
 Based on the assessment data, the major nursing
diagnoses are:
 Disturbed body image related to permanent alteration in
structure and/or function.
 Deficient knowledge related to the condition, prognosis,
treatment, self-care, and discharge needs.
 Risk for peripheral neurovascular dysfunction related to
mechanical compression (cast or brace).
 Risk for impaired skin integrity related to cast
application, traction or surgery.
 Risk for impaired parenting related to maladaptive coping
strategies secondary to diagnosis of talipes deformity.

19.  The major nursing care planning goals for patients with
congenital talipes equinovarus (clubfoot) are:
 Parents verbalize acceptance of self in the situation
 Family discuss about situation and changes that would have
occurred.
 Parents develop realistic goals/plans for the future.
 Parents explain disease state, recognizes the need for
medications and understands treatments.
 Parents demonstrate how to incorporate new health regimen into
lifestyle.
 Parents exhibit ability to deal with health situation and remain in
control of life.
 Parents demonstrate an understanding of plan to heal tissue and
prevent injury.
 Parents describe measures to protect and heal the tissue,
including wound care.

20.  Protect skin integrity. Monitor site of impaired tissue
integrity at least once daily for color changes, redness, swelling,
warmth, pain, or other signs of infection; monitor patient’s skin
care practices, noting type of soap or other cleansing agents
used, temperature of water, and frequency of skin cleansing; and
provide gloves or clip the nails if necessary to avoid damaging
the skin with scratches.
 Promote acceptance of body image. Acknowledge and accept
an expression of feelings of frustration, dependency, anger, grief,
and hostility; support verbalization of positive or negative
feelings about the actual or perceived loss; and be realistic and
positive during treatments, in health teaching, and in setting
goals within limitations.
 Provide health education. Include the parents in creating the
teaching plan, beginning with establishing objectives and goals
for learning at the beginning of the session; provide clear,
thorough, and understandable explanations and demonstrations;
and render positive, constructive reinforcement of learning.


21.  Goals are met as evidenced by:
 Parents verbalized acceptance of self in situation
 Family discussed about situation and changes that would have
occurred.
 Parents developed realistic goals/plans for the future.
 Parents explained disease state, recognizes need for medications,
and understands treatments.
 Parents demonstrated how to incorporate new health regimen into
lifestyle.
 Parents exhibited ability to deal with health situation and remain in
control of life.
 Parents demonstrated an understanding of plan to heal tissue and
prevent injury.
 Parents described measures to protect and heal the tissue, including
wound care.

22.  Because doctors don't know what causes clubfoot, you can't
completely prevent it. However, if you're pregnant, you can
do things to limit your baby's risk of birth defects, such as:
 Not smoking or spending time in smoky environments
 Not drinking alcohol
 Avoiding drugs not approved by your doctor

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